Injection drug use infective endocarditis: clinical features and therapeutic challanges

Abstract Introduction Injection drug use (IDU) is a known risk factor for infective endocarditis (IE) and is associated with frequent recurrences, but its prognostic impact is still debated. Moreover, the potential futility of surgery in this population is an unsolved matter. Purpose We aimed to determine the clinical characteristics, the therapeutic strategy, and the prognostic impact of injection drug use IE (IDUIE). Method We retrospectively included in the analysis 454 consecutive episodes of definite active IE admitted in a single surgical centre from January 2012 to December 2020; 14 out of them where a subsequent infective episode of the same patient. Results IDUIE cases were 63 (13.8%), without significant proportional differences over time. IDUIE patients were significantly younger (43.95±10.12 vs 67.84±13.33, p 0.00) and presented fewer comorbidities (p<0.001). They were admitted with a first episode of IE only in 60.3% of cases vs 92.8% of non-IDU (p<0.001). Embolism was present at admission in a higher percentage (60.3 vs 38.4%, p<0.001). IDUIE was more frequently associated with spondylodiscitis (15.9 vs 7.4%, p=0.026). The infection was less frequently left-sided than in non-IDU patients (57.1 vs 97.2%, p<0.001) and was more often polimicrobic (12.7 vs 4.9%, p=0.015). Most patients were positive for Staphylococcus aureus (54.0 vs 12.8%, p<0.001), while Streptococci were significantly less frequent in patients with IDUIE (11 vs 25%, p=0.015). The proportion of patients undergoing surgery was similar among the two groups (85.5 vs 78.8%, NS). IDUIE patients treated medically for absence of surgical indication had a better survival than patients undergoing surgery for complicated IE (p<0.001). IDUIE was associated with a higher proportion of relapse during follow-up (28.3 vs 3.3%, p<0.001). It was not associated with higher mortality (Figure 1) but was an independent predictor of mortality in multivariable analysis including age (HR per unit 1.048, 95% CI 1.038–1.063, p=0.00) and drug abuse (HR 3.2, 95% CI 1.8–5.6, p=0.00; Figure 2). Among IDUIE patients, we did not find predictors of futility of surgery, not even multiple relapses. Conclusions IDUIE represents a considerable proportion of overall cases of IE, mainly affecting young people. Staphylococcus aureus is the most common microbiologic agent. IDUIE is not associated with higher mortality but drug abuse is an independent predictor of mortality. Considering that patient with uncomplicated IE treated medically have a better prognosis, we should reserve surgery to patients with a strict indication for it. On the other hand, since there are no predictors of futility of surgery, all patients with a complicated IE should undergo surgery without delay. The main determinant of prognosis in these patients is not IE but drug abuse itself. For this reason, increased focus on addiction treatment following hospital discharge is mandatory to improve long term prognosis. FUNDunding Acknowledgement Type of funding sources: None.

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Maternal Bacteremia Caused by Staphylococcus Aureus With a Focus on Infective Endocarditis

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa239 ◽

2020 ◽

Vol 7 (8) ◽

Author(s):

Morgan K Morelli ◽

Michael P Veve ◽

Mahmoud A Shorman

Keyword(s):

Staphylococcus Aureus ◽

Infective Endocarditis ◽

Drug Use ◽

Hospital Mortality ◽

Injection Drug Use ◽

Pregnant Patient ◽

Infectious Complications ◽

Injection Drug ◽

Secondary Outcome ◽

Targeted Interventions

Abstract Background Sepsis is an important cause of morbidity and mortality in the pregnant patient. Injection drug use in pregnant populations has led to increased cases of bacteremia and infective endocarditis (IE) due to Staphylococcus aureus. We describe all cases of S. aureus bacteremia and IE among admitted pregnant patients at our hospital over a 6-year period. Methods This was a retrospective review of pregnant patients hospitalized with S. aureus bacteremia between April 2013 and November 2019. Maternal in-hospital mortality and fetal in-hospital mortality were the primary outcomes measured; the secondary outcome was the rate of 6-month maternal readmission. Results Twenty-seven patients were included; 15 (56%) had IE. The median (interquartile range [IQR]) age was 29 (25–33) years; 22 (82%) patients had methicillin-resistant S. aureus. Infection onset occurred at a median (IQR) of 29 (23–34) weeks’ gestation. Twenty-three (85%) mothers reported active injection drug use, and 21 (78%) were hepatitis C seropositive. Fifteen (56%) mothers required intensive care unit (ICU) care. Twenty-two (81%) patients delivered 23 babies; of the remaining 5 mothers, 3 (11%) were lost to follow-up and 2 (7%) terminated pregnancy. Sixteen (73%) babies required neonatal ICU care, and 4/25 (16%) infants/fetuses died during hospitalization. One (4%) mother died during hospitalization, and 7/26 (27%) mothers were readmitted to the hospital within 6 months for infectious complications. Conclusions Injection drug use is a modifiable risk factor for S. aureus bacteremia in pregnancy. Fetal outcomes were poor, and mothers were frequently readmitted secondary to infection. Future targeted interventions are needed to curtail injection drug use in this population.

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Patients with infective endocarditis and history of injection drug use in a Swedish referral hospital during 10 years

BMC Infectious Diseases ◽

10.1186/s12879-021-05914-1 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Anna Damlin ◽

Katarina Westling

Keyword(s):

Infective Endocarditis ◽

Drug Use ◽

Injection Drug Use ◽

Clinical Characteristics ◽

National Registry ◽

Injection Drug ◽

University Hospital ◽

Prosthetic Heart Valves ◽

Increased Risk ◽

History Of

Abstract Background Patients with injection drug use (IDU) have increased risk of developing infective endocarditis (IE). Previous studies have reported recurrent IE, increased duration of hospital stay, poor adherence and compliance as well as higher mortality and worse outcomes after surgery in the IDU-IE patient group. Further studies are needed to provide a basis for optimized care and prevention of readmissions in this population. This study aims to describe the clinical characteristics and outcomes among patients with IDU-IE. Methods Data of adults with IDU-IE and non-IDU-IE, treated between 2008 and 2017 at the Karolinska University Hospital in Stockholm were obtained from the Swedish National Registry of Infective Endocarditis. Clinical characteristics, microbiological results, treatment durations, results from echocardiography and in-hospital mortality were compared between the groups. Results Of the total 522 patients, 165 (32%) had IDU-IE. Patients with IDU-IE were younger than the patients with non-IDU-IE (mean age IDU-IE: 41.6 years, SD 11.9 years; non-IDU-IE: 64.3 years, SD 16.4 years; P < 0.01). No difference in distribution of gender was observed, 33% were females in both the IDU-IE and the non-IDU-IE group. History of previous IE (IDU-IE: n = 49, 30%; non-IDU-IE: n = 34, 10%; P < 0.01) and vascular phenomena (IDU-IE: n = 101, 61%; non-IDU-IE: n = 120, 34%; P < 0.01) were more common among patients with IDU-IE while prosthetic heart valves (IDU-IE: n = 12, 7%; non-IDU-IE: n = 83, 23%; P < 0.01) and known valvular disease (IDU-IE: n = 3, 2%; non-IDU-IE: n = 78, 22%; P < 0.01) were more common among patients with non-IDU-IE. Aetiology of Staphylococcus aureus (IDU-IE: n = 123, 75%; non-IDU-IE: n = 118, 33%; P < 0.01) as well as tricuspid (IDU-IE: n = 91, 55%; non-IDU-IE: n = 23, 6%; P < 0.01) or pulmonary valve vegetations (IDU-IE: n = 7, 4%; non-IDU-IE: n = 2, 1%; P < 0.01) were more common in the IDU-IE group. The overall incidence of IDU-IE decreased during the study period, while the incidence of definite IE increased (P < 0.01). Conclusions This study presents that patients with IDU-IE were younger, less frequently treated with surgery and had higher prevalence of vascular phenomena and history of previous IE, aspects that are important for improved management of this population.

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Infective endocarditis secondary to injection drug use: A survey of Canadian cardiac surgeons

The Annals of Thoracic Surgery ◽

10.1016/j.athoracsur.2020.12.003 ◽

2021 ◽

Author(s):

Kevin R. An ◽

Jessica G.Y. Luc ◽

Derrick Y. Tam ◽

Olina Dagher ◽

Rachel Eikelboom ◽

...

Keyword(s):

Infective Endocarditis ◽

Drug Use ◽

Injection Drug Use ◽

Injection Drug ◽

Cardiac Surgeons

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Injection Drug Use–Associated Infective Endocarditis

JAMA ◽

10.1001/jama.2018.14071 ◽

2018 ◽

Vol 320 (18) ◽

pp. 1939 ◽

Cited By ~ 1

Author(s):

David Phillip Serota ◽

J. Deanna Wilson ◽

Jessica S. Merlin

Keyword(s):

Infective Endocarditis ◽

Drug Use ◽

Injection Drug Use ◽

Injection Drug

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The Need for Multidisciplinary Hospital Teams for Injection Drug Use-Related Infective Endocarditis

Journal of Addiction Medicine ◽

10.1097/adm.0000000000000916 ◽

2021 ◽

Vol Publish Ahead of Print ◽

Author(s):

Melissa B. Weimer ◽

Caroline G. Falker ◽

Nikhil Seval ◽

Marjorie Golden ◽

Sarah C. Hull ◽

...

Keyword(s):

Infective Endocarditis ◽

Drug Use ◽

Injection Drug Use ◽

Injection Drug ◽

Hospital Teams

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Drug Use and Postoperative Mortality Following Valve Surgery for Infective Endocarditis: A Systematic Review and Meta-analysis

Clinical Infectious Diseases ◽

10.1093/cid/ciy1064 ◽

2018 ◽

Vol 69 (7) ◽

pp. 1120-1129 ◽

Cited By ~ 15

Author(s):

Ryan Hall ◽

Michael Shaughnessy ◽

Griffin Boll ◽

Kenneth Warner ◽

Helen W Boucher ◽

...

Keyword(s):

Systematic Review ◽

Infective Endocarditis ◽

Drug Use ◽

Injection Drug Use ◽

Systematic Reviews ◽

Meta Analysis ◽

Postoperative Mortality ◽

Valve Surgery ◽

Injection Drug ◽

Significant Difference

AbstractBackgroundInfective endocarditis (IE) often requires surgical intervention. An increasingly common cause of IE is injection drug use (IDU-IE). There is conflicting evidence on whether postoperative mortality differs between people with IDU-IE and people with IE from etiologies other than injection drug use (non–IDU-IE). In this manuscript, we compare short-term postoperative mortality in IDU-IE vs non–IDU-IE through systematic review and meta-analysis.MethodsThe review was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Publication databases were queried for key terms included in articles up to September 2017. Randomized controlled trials, prospective cohorts, or retrospective cohorts that reported on 30-day mortality or in-hospital/operative mortality following valve surgery and that compared outcomes between IDU-IE and non–IDU-IE were included.ResultsThirteen studies with 1593 patients (n = 341 [21.4%] IDU-IE) were included in the meta-analysis. IDU-IE patients more frequently had tricuspid valve infection, Staphylococcus infection, and heart failure before surgery. Meta-analysis revealed no statistically significant difference in 30-day postsurgical mortality or in-hospital mortality between the 2 groups.ConclusionsDespite differing preoperative clinical characteristics, early postoperative mortality does not differ between IDU-IE and non–IDU-IE patients who undergo valve surgery. Future research on long-term outcomes following valve replacement is needed to identify opportunities for improved healthcare delivery with IDU-IE.

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Use of ICD-10 Codes for Identification of Injection Drug Use–Associated Infective Endocarditis Is Nonspecific and Obscures Critical Findings on Impact of Medications for Opioid Use Disorder

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa414 ◽

2020 ◽

Vol 7 (10) ◽

Author(s):

Laura R Marks ◽

Nathanial S Nolan ◽

Linda Jiang ◽

Dharushana Muthulingam ◽

Stephen Y Liang ◽

...

Keyword(s):

Infective Endocarditis ◽

Drug Use ◽

Injection Drug Use ◽

Opioid Use Disorder ◽

Injection Drug ◽

Diagnosis Code ◽

Opioid Use ◽

Diagnosis Codes ◽

All Cause Mortality ◽

Icd 10

Abstract Background No International Classification of Diseases, 10th revision (ICD-10), diagnosis code exists for injection drug use–associated infective endocarditis (IDU-IE). Instead, public health researchers regularly use combinations of nonspecific ICD-10 codes to identify IDU-IE; however, the accuracy of these codes has not been evaluated. Methods We compared commonly used ICD-10 diagnosis codes for IDU-IE with a prospectively collected patient cohort diagnosed with IDU-IE at Barnes-Jewish Hospital to determine the accuracy of ICD-10 diagnosis codes used in IDU-IE research. Results ICD-10 diagnosis codes historically used to identify IDU-IE were inaccurate, missing 36.0% and misclassifying 56.4% of patients prospectively identified in this cohort. Use of these nonspecific ICD-10 diagnosis codes resulted in substantial biases against the benefit of medications for opioid use disorder (MOUD) with relation to both AMA discharge and all-cause mortality. Specifically, when data from all patients with ICD-10 code combinations suggestive of IDU-IE were used, MOUD was associated with an increased risk of AMA discharge (relative risk [RR], 1.12; 95% CI, 0.48–2.64). In contrast, when only patients confirmed by chart review as having IDU-IE were analyzed, MOUD was protective (RR, 0.49; 95% CI, 0.19–1.22). Use of MOUD was associated with a protective effect in time to all-cause mortality in Kaplan-Meier analysis only when confirmed IDU-IE cases were analyzed (P = .007). Conclusions Studies using nonspecific ICD-10 diagnosis codes for IDU-IE should be interpreted with caution. In the setting of an ongoing overdose crisis and a syndemic of infectious complications, a specific ICD-10 diagnosis code for IDU-IE is urgently needed.

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Brucella Endocarditis in Persons Who Inject Drugs

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa063 ◽

2020 ◽

Vol 7 (4) ◽

Author(s):

John M Cafardi ◽

Douglas Haas ◽

Thomas Lamarre ◽

Judith Feinberg

Keyword(s):

Infective Endocarditis ◽

Drug Use ◽

Injection Drug Use ◽

Injection Drug Users ◽

Drug Users ◽

Cardiac Involvement ◽

Injection Drug ◽

Persons Who Inject Drugs ◽

Brucella Infection

Abstract We report 2 cases of infective endocarditis in injection drug users due to Brucella infection. Although cardiac involvement is a frequent sequela of brucellosis and endocarditis is often seen with injection drug use, Brucella endocarditis in persons who inject drugs without zoonotic exposure has not been reported to date.

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Septic Arthritis and the Opioid Epidemic: 1465 Cases of Culture-Positive Native Joint Septic Arthritis From 1990–2018

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa089 ◽

2020 ◽

Vol 7 (3) ◽

Author(s):

John J Ross ◽

Kevin L Ard ◽

Narath Carlile

Keyword(s):

Staphylococcus Aureus ◽

Drug Use ◽

Synovial Fluid ◽

Septic Arthritis ◽

Injection Drug Use ◽

Injection Drug ◽

Facet Joints ◽

Cell Counts ◽

Culture Positive ◽

Fluid Cell

Abstract Background The clinical spectrum of septic arthritis in the era of the opioid crisis is ill-defined. Methods This is a retrospective chart review of 1465 cases of culture-positive native joint septic arthritis at Boston teaching hospitals between 1990 and 2018. Results Between 1990–2008 and 2009–2018, the proportion of septic arthritis cases involving people who inject drugs (PWID) rose from 10.3% to 20% (P < .0000005). Overall, methicillin-sensitive Staphylococcus aureus (MSSA) caused 41.5% of cases, and methicillin-resistant Staphylococcus aureus (MRSA) caused 17.9%. Gram-negative rods caused only 6.2% of cases. Predictors of MRSA septic arthritis included injection drug use (P < .001), bacteremia (P < .001), health care exposure (P < .001), and advancing age (P = .01). Infections with MSSA were more common in PWID (56.3% vs 38.8%; P < .00001), as were infections with MRSA (24% vs 16.8%; P = .01) and Serratia sp. (4% vs 0.4%; P = .002). Septic arthritis in the setting of injection drug use was significantly more likely to involve the sacroiliac, acromioclavicular, and facet joints; 36.8% of patients had initial synovial fluid cell counts of <50 000 cells/mm3. Conclusions Injection drug use has become the most common risk factor for septic arthritis in our patient population. Septic arthritis in PWID is more often caused by MRSA, MSSA, and Serratia sp., and is more prone to involve the sacroiliac, acromioclavicular, sternoclavicular, and facet joints. Synovial fluid cell counts of <50 000 cells/mm3 are common in culture-positive septic arthritis.

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Staphylococcus aureus injection drug use-associated bloodstream infections are propagated by community outbreaks of diverse lineages

Communications Medicine ◽

10.1038/s43856-021-00053-9 ◽

2021 ◽

Vol 1 (1) ◽

Author(s):

Laura R. Marks ◽

Juan J. Calix ◽

John A. Wildenthal ◽

Meghan A. Wallace ◽

Sanjam S. Sawhney ◽

...

Keyword(s):

Staphylococcus Aureus ◽

Drug Use ◽

Injection Drug Use ◽

Academic Medical Center ◽

Bloodstream Infections ◽

Clonal Expansion ◽

The United States ◽

Injection Drug ◽

Comparative Genomic ◽

Molecular Features

Abstract Background The ongoing injection drug use (IDU) crisis in the United States has been complicated by an emerging epidemic of Staphylococcus aureus IDU-associated bloodstream infections (IDU-BSI). Methods We performed a case-control study comparing S. aureus IDU-BSI and non-IDU BSI cases identified in a large US Midwestern academic medical center between Jan 1, 2016 and Dec 21, 2019. We obtained the whole-genome sequences of 154 S. aureus IDU-BSI and 91 S. aureus non-IDU BSI cases, which were matched with clinical data. We performed phylogenetic and comparative genomic analyses to investigate clonal expansion of lineages and molecular features characteristic of IDU-BSI isolates. Results Here we show that patients with IDU-BSI experience longer durations of bacteremia and have lower medical therapy completion rates. In phylogenetic analyses, 45/154 and 1/91 contemporaneous IDU-BSI and non-IDU BSI staphylococcal isolates, respectively, group into multiple, unique clonal clusters, revealing that pathogen community transmission distinctively spurs IDU-BSI. Lastly, multiple S. aureus lineages deficient in canonical virulence genes are overrepresented among IDU-BSI, which may contribute to the distinguishable clinical presentation of IDU-BSI cases. Conclusions We identify clonal expansion of multiple S. aureus lineages among IDU-BSI isolates, but not non-IDU BSI isolates, in a community with limited access to needle exchange facilities. In the setting of expanding numbers of staphylococcal IDU-BSI cases consideration should be given to treating IDU-associated invasive staphylococcal infections as a communicable disease.

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